What happens to dementia patients in the evening? Understanding Sundowning

According to the Alzheimer’s Association, up to 20% of people with Alzheimer's experience sundowning, a state of increased confusion and agitation in the late afternoon and evening. This phenomenon describes the behavioral changes that occur and helps answer the question, what happens to dementia patients in the evening?

Quick Summary

As daylight fades, dementia patients may exhibit increased confusion, anxiety, and agitation, a phenomenon known as sundowning. This behavior is linked to disrupted internal body clocks, environmental triggers like low light, and fatigue, making evenings particularly challenging for both patients and caregivers. Implementing calming routines, managing environmental factors, and understanding triggers can help mitigate these symptoms.

Key Points

• Sundowning Explained: The term refers to increased confusion, anxiety, and agitation that affects many dementia patients in the late afternoon and evening.

• Common Triggers: Disrupted circadian rhythms, end-of-day fatigue, low light, and increased shadows can all contribute to sundowning behaviors.

• Routine is Key: Maintaining a consistent daily schedule for meals, activities, and bedtime helps provide security and predictability, which can reduce evening anxiety.

• Environmental Management: Adjusting the home environment by maximizing daytime light and reducing evening stimulation is an effective strategy for minimizing sundowning symptoms.

• Calm Approach: Caregivers should respond with patience, validation, and distraction rather than confrontation during an episode of late-day confusion.

• Medical Options: In some cases, a healthcare provider may recommend medications like melatonin, antidepressants, or antipsychotics to help manage severe or persistent symptoms.

What is Sundowning?

Sundowning is not a disease itself but a collection of behavioral symptoms that occur in individuals with dementia as daylight begins to fade. These symptoms, which often manifest in the late afternoon or early evening, can include heightened confusion, anxiety, restlessness, and, in some cases, aggression. It is a distressing experience for both the person with dementia and their caregiver, often disrupting sleep patterns and daily routines.

Symptoms of Sundowning

The signs of sundowning can vary widely among individuals, but common indicators include:

• Increased confusion and disorientation: A person may forget where they are, what time it is, or may not recognize familiar people.
• Agitation and restlessness: This can involve pacing, rocking, or an inability to sit still.
• Anxiety and fear: The individual may become easily frightened or express irrational fears.
• Hallucinations and delusions: Seeing or hearing things that aren't there is a possible symptom, as is holding false beliefs.
• Wandering: A person may feel the need to walk around and may try to leave the house.
• Aggressive behavior: This can include verbal outbursts or, in rare cases, physical aggression.

Why does sundowning occur?

While the exact cause of sundowning is not fully understood, research points to several contributing factors:

• Circadian rhythm disruption: Dementia can damage the part of the brain that regulates the body's internal clock. This can lead to a mix-up in the sleep-wake cycle, making the person feel sleepy during the day and awake at night.
• Fatigue: Physical and mental exhaustion from a full day of activities can heighten irritability and confusion as evening approaches.
• Environmental changes: As the sun sets, shadows and low lighting can increase confusion and trigger fear, especially in someone with vision problems.
• Pain and discomfort: Undiagnosed pain, hunger, or a full bladder can contribute to restlessness and agitation.
• Medication side effects: Some medications can affect a person's behavior, with certain side effects becoming more apparent in the evening.

Management Strategies for Evening Behaviors

Effectively managing sundowning requires a combination of behavioral, environmental, and, in some cases, medical approaches. The goal is to create a predictable, calming environment that minimizes triggers.

Non-Medication Strategies

Caregivers can implement several non-medical techniques to help manage sundowning symptoms:

1. Maintain a consistent routine: A predictable schedule for meals, waking, and bedtime can provide a sense of security. Schedule more challenging tasks, like doctor's appointments, for the morning when the person is likely to be less confused.
2. Adjust the environment: Maximize exposure to natural light during the day. In the evening, close curtains before dark and use bright, artificial lighting to minimize shadows that can be frightening.
3. Encourage daytime activity: Regular physical activity, such as walking or light exercise, can help improve nighttime sleep. However, avoid overstimulation late in the day.
4. Create a calming evening ritual: Introduce a quiet, soothing routine as the sun begins to set. This could include playing soft music, reading a book together, or looking at family photos.
5. Listen and reassure: If agitation occurs, respond calmly and reassuringly. Avoid arguments or corrections. Validate their feelings and gently redirect their attention to a pleasant activity.
6. Offer a relaxing snack: A light, caffeine-free snack, such as warm milk or herbal tea, can be comforting before bed.

The Importance of a Structured Day

A well-structured day is one of the most effective tools for preventing and managing sundowning. A predictable rhythm of activities helps orient the person with dementia and reduces the anxiety that can be triggered by confusion and uncertainty. This includes:

• Having meals at the same time each day.
• Scheduling daily walks or other light exercise.
• Incorporating meaningful, low-stress activities.
• Keeping daytime naps short and early in the day to promote better nighttime sleep.

A comparison of daytime vs. evening care strategies

Care Strategy	Daytime Approach	Evening Approach
Environment	Maximize natural light exposure; encourage moderate stimulation.	Close curtains, use bright artificial light to reduce shadows; minimize noise and clutter.
Activities	Schedule walks, social visits, and stimulating tasks.	Offer calm, low-stress activities like listening to music or reading.
Schedule	Keep a consistent routine for meals, activities, and rest.	Transition to a quiet, relaxing routine as daylight fades.
Napping	Keep naps short and limit them to the early afternoon.	Discourage late-day napping to improve nighttime sleep.
Nutrition	Provide a larger, more satisfying meal at lunchtime.	Offer a lighter evening meal and caffeine-free drinks.

Medical Approaches and Professional Help

For some individuals, behavioral and environmental strategies may not be enough. In these cases, a healthcare provider may suggest medical interventions.

Potential Medication Options

• Melatonin: A naturally occurring hormone that regulates sleep, melatonin supplements may help reset the body's internal clock.
• Antidepressants or anti-anxiety medications: These may be used to address underlying depression or anxiety that is exacerbating sundowning symptoms.
• Antipsychotics: In cases of severe aggression, hallucinations, or delusions, a doctor may prescribe a low dose of an atypical antipsychotic, carefully weighing the potential risks and benefits.

Note: It is crucial to consult a healthcare provider before starting or changing any medication. A doctor can evaluate potential side effects and interactions.

The Caregiver's Role and Support

Dealing with sundowning can be emotionally and physically draining for caregivers. Managing your own stress is vital for providing consistent, compassionate care.

Tips for Caregivers

• Seek support: Connect with other caregivers through support groups or online forums to share experiences and coping strategies.
• Prioritize self-care: Ensure you are getting enough rest and taking breaks. Caregiver burnout is a serious risk.
• Keep a log: Track the person's behavior, noting the timing of sundowning episodes and any potential triggers. This can help identify patterns and inform management strategies.
• Stay calm: Your stress and frustration can be perceived by the person with dementia, increasing their own anxiety. Practice deep breathing and patience.

When to seek professional help

Contact a healthcare provider or a geriatrician if:

• Sundowning symptoms appear suddenly or worsen rapidly, as this could indicate an underlying medical issue like a urinary tract infection.
• The person's behavior becomes aggressive or potentially harmful to themselves or others.
• You feel overwhelmed and unable to manage the behaviors on your own.

Conclusion: Navigating the Evening with Confidence

In summary, understanding what happens to dementia patients in the evening requires acknowledging the complex phenomenon of sundowning. This involves recognizing its symptoms, identifying potential triggers, and implementing consistent, calming strategies. By creating a predictable daily routine, managing the environment, and employing soothing evening rituals, caregivers can significantly reduce the distress associated with late-day confusion. Collaboration with a healthcare professional can provide additional support and guidance, ensuring the best possible quality of life for both the individual with dementia and their care team. Empower yourself with knowledge and patience, and remember that professional support is available to help navigate these challenges. For more information on managing behavioral symptoms, visit The Alzheimer's Association website.

Frequently Asked Questions

What is sundowning in dementia?

Sundowning is a term used to describe increased confusion, anxiety, and agitation that can occur in people with dementia during the late afternoon or early evening. It is not a disease but a pattern of behaviors linked to the disease's progression.

How can I tell if a loved one is sundowning?

Look for signs like increased restlessness, anxiety, pacing, confusion about time or place, and potentially aggressive or fearful behavior that starts or worsens as daylight fades. Some people may also experience hallucinations or delusions.

What are common triggers for sundowning behavior?

Triggers can include mental and physical exhaustion, changes in the body's internal clock, low lighting and shadows that cause fear, an unfamiliar environment, boredom, pain, or an underlying illness like a UTI.

How should a caregiver respond during a sundowning episode?

Stay calm and reassuring, avoid correcting or arguing, and try to distract the person with a favorite activity, a snack, or gentle music. Ensure the environment is safe and well-lit to minimize fear.

Can diet affect sundowning?

Yes, certain dietary habits can influence sundowning. Limiting caffeine and sugar in the late afternoon and evening is often recommended. Providing a larger lunch and a lighter dinner can also help promote better sleep.

Are there medications to treat sundowning?

While non-medication strategies are usually the first approach, a healthcare provider might consider medications like melatonin, antidepressants, or, in severe cases, atypical antipsychotics. Any medication should be used under a doctor's supervision.

What kind of evening routine is best for someone with dementia?

A calming and consistent routine is best. This could include dimming lights, playing soothing music, and engaging in a simple, relaxing activity like looking at family photos. Avoid stimulating activities like watching intense TV shows.